This is the third and final part of our series on the remote monitoring 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 reimbursement for Remote Patient Monitoring in 2018, there have been a remarkable number of changes shaping how providers offer remote monitoring 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 and clarifications to 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 remote monitoring services , and reimbursement. 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 remote monitoring.
This information was compiled with the help of outside counsels. We will note this information does not constitute legal advice to the reader, nor does it confer a guarantee of reimbursement for any claims.
If you’re interested in diving deeper into remote monitoring billing and coding landscape, check out our free remote monitoring billing and coding guide, which covers the 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. However, 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, 99453, 99454, 99457, and 99458 are not limited to particular conditions or medical specialties. Providers are reminded to bill the most specific codes pertaining to the services being rendered.
Physicians and Qualified Health Care Professionals or “QHCPs” who may bill evaluation and management codes may report 99091. That would include physicians, nurse practitioners, physicians assistants, certified nurse specialists, and certified nurse mid-wifes.
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 in some instances it may be appropriate to bill 99457 and 99091 at the same time.
No. CPT code 99453 can only be reported by only one practitioner, once per patient, per episode of care, per 30-day period, 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 by one practitioner, 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.
Yes, albeit allowances during the COVID-19 PHE. CMS has required 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 to provide some RPM services under the general supervision of the billing practitioner. When a billing practitioner reports clinical staff time, the billing practitioner bills clinical staff members’ time on an “incident-to” basis. This does not replace the need for the billing provider/QHCP to complete medical decision making as part of the services being provided, but rather delegate some coordination efforts under their general supervision.
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 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, state medical boards, local regulations, and facility policy (which may include training, education, insurance, and other human resource considerations). Providers should consider applicable scope of practice laws in the patient’s state to determine who can and cannot provide allowable care coordination and work under the general supervision of the billing provider.
No. These codes are independent of 99457 and 99458, provided they are being reported for remote physiologic monitoring.
Yes. CMS noted in the 2021 Rule that 99453 and 99454 require 16-days of data readings within a 30-day period. CMS has also instituted a temporary allowance of at least 2 (two) days of data for patients diagnosed with, or suspected of having COVID-19.
For remote physiologic monitoring services, the beneficiary must use a medical device as defined by the U.S. Food and Drug Administration (FDA) in the Food, Drug & Cosmetics Act (FD&C Act). 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 Consider
Part 2: CPT® Codes 99457, 99458, and 99091: What Healthcare Providers Should Consider
Part 3 (current): Remote Monitoring CPT® Codes Frequently Asked Questions