4 Things to Know About Remote Patient Monitoring Reimbursement

Effectively launching an RPM program requires the completion of several essential steps. These include everything from choosing the remote patient monitoring system that will help drive your program and its growth to developing effective mechanisms for educating patients on RPM.

There is also the very important need to understand how much you will get paid for your services. Once you learn the nuts and bolts of RPM reimbursement, you may decide to quickly move from considering a remote patient monitoring program to launching a program as soon as possible.

Below are four things to know about remote patient monitoring reimbursement. Note: The RPM coding and billing information shared below speaks to the rules and rates for physician practices. For 2024, CMS now reimburses rural health clinics (RHCs) and federally qualified health centers (FQHCs) for RPM. These organizations follow different coding and billing rules and get paid different amounts for RPM. RHCs and FQHCs interested in learning about RPM, including coding and billing, should download this helpful guide.

1. Coverage of Remote Patient Monitoring

Remote patient monitoring is covered by Medicare. As of September 2024, it's also covered by 42 state Medicaid programs, according to the Center for Connected Health Policy. A growing number of commercial payers are covering remote patient monitoring as well.

2. Getting Paid for Remote Patient Monitoring

What can you expect to get paid for providing remote patient monitoring services? While CMS has adjusted RPM reimbursement over the years, it remains one of the better paying Medicare care management programs.

Using average Medicare reimbursement for 2024, here's how RPM reimbursement breaks down:

• Medicare pays $19 for initial patient enrollment into an RPM. This includes RPM device setup and the delivering of patient education on using the device and receiving RPM services.
• Medicare provides a base monthly payment of about $46 for monitoring patient data transmitted from the RPM device and ongoing management of the device.
• Medicare provides a monthly payment of about $48 for spending 20 minutes communicating with the patient or a caregiver about the transmitted data and changes to the care management plan.
• Medicare will provide an additional monthly payment of about $38 if communication with a patient or caregiver exceeds 20 minutes but is less than 40 minutes. If communication requires 40 or more minutes, Medicare will provide an additional — and final — monthly payment of $38. There are no additional payments for communication of 1 hour or more.

Here's what RPM billing looks like:

A practice will typically furnish about 20 minutes of RPM care management per month to a patient, which will bring the total monthly reimbursement to around $94 per Medicare beneficiary. The maximum amount a single remote patient monitoring patient can earn a practice is up to around $170 per month.

While that may not sound like a large figure on its own, successful RPM programs enroll many beneficiaries and then grow over time. If your practice enrolls just 100 patients into its RPM program and these patients each receive the minimum care management services, you will earn about $112,800 in annual Medicare remote patient monitoring reimbursement. You will also earn the one-time reimbursement associated with the initial patient setup and enrollment, netting you an additional $1,900. After covering expenses associated with RPM, the program will yield significant, recurring, and scalable profit.

Before we go on to discuss how to code for remote patient monitoring, we'd be remiss not to mention the highly effective way to further maximize the benefits of remote patient monitoring for patients and your organization: providing RPM in conjunction with chronic care management (CCM) as part of comprehensive care management program. When practices pair RPM and CCM, patients receive more ongoing and personalized care and providers generate more revenue. In fact, 100 patients receiving RPM and CCM would generate nearly $132,000 in annual revenue. You will also earn the one-time reimbursement associated with the initial enrollment, bringing in another $1,900.  

3. RPM Coding Rules

Coming back to our discussion focused on remote patient monitoring patients: How will you earn all that reimbursement? By properly coding your RPM, of course. Let's briefly examine the CPT codes assigned to RPM.

Most remote patient monitoring services will be billed under four CPT codes. These codes are typically split into two categories: There are the RPM "service codes," which include CPT 99453 and CPT 99454, and the and timed RPM "management codes," which include CPT 99457 and CPT 99458.

The RPM service codes descriptors are as follows:

• CPT 99453 — Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment
• CPT 99454 — Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days

The RPM management codes descriptors are as follows

• CPT 99457 — Remote physiologic monitoring treatment management services, clinical staff/physician/ other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; initial 20 minutes
• CPT 99458 — Remote physiologic monitoring treatment management services, clinical staff/physician/ other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; additional 20 minutes

For more detailed information about remote patient monitoring requirements for billing and coding, we recommend downloading this RPM billing guide. If you are looking for information about the original code for billing RPM (CPT 99091), including an explanation of why it's a CPT code you will probably no longer use, check out this quick guide.

4. CMS Guidelines for Remote Patient Monitoring

To reduce the likelihood of claims denials and avoid potential scrutiny of your billing practices, you must understand the CMS guidelines for remote patient monitoring.

To qualify for reimbursement, CMS expects providers to ensure they follow these RPM requirements:

• Charge Medicare Part B patients a 20% percent copayment. This copay is generally not waivable, but it may be covered if a patient has supplemental coverage or Medicaid. Note: Commercial payers establish their own copay policies and may choose not to require a copay.
• Patients must consent — in writing or verbally — to receiving RPM services.
• The RPM service must be ordered by a physician or other "qualified healthcare professional," such as a nurse practitioner, certified nurse specialist, or physician assistant.
• Patients must be monitored for at least 16 days to be applied to a billing period. This is a requirement to bill for CPT 99454.
• Data must be wirelessly synced for evaluation.

In addition, CMS stipulates that RPM devices must meet the U.S. Food and Drug Administration's definition of a medical device. Examples of common RPM devices include blood pressure monitors and weight scales, like those devices developed by Pylo.

Keeping More of Your Remote Patient Monitoring Reimbursement

While remote patient monitoring can serve as a significant income-generator, that will only be the case if your practice keeps expenses associated with running the program to a minimum and has processes in place to better ensure you are paid in full for RPM services rendered. These are just a few of the areas where the Prevounce Remote Patient Monitoring system shines.

With Prevounce, setup, integration, and ongoing management of an RPM program, including coding and billing for these services, is simple and efficient. There may be no simpler or more effective way to launch and scale an RPM program (or comprehensive care management program, if you choose to go down this path).

Want to learn more about why Prevounce is the RPM platform of choice for organizations nationwide? Schedule a no-obligation demo of Prevounce Remote Patient Monitoring. If you're not quite ready for a demo, please call (800) 618-7738 or email sales@prevounce.com to connect with one of Prevounce's remote patient monitoring experts. We're standing by, ready to answer your questions and help your practice take the next steps toward bringing RPM to your patients.

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Disclaimer

Health economic and reimbursement information provided by Prevounce is gathered from third-party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules, and policies. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice.

Prevounce encourages providers to submit accurate and appropriate claims for services. It is always the provider’s responsibility to determine medical necessity, the proper site for delivery of any services, and to submit appropriate codes, charges, and modifiers for services rendered. It is also always the provider’s responsibility to understand and comply with Medicare national coverage determinations (NCD), Medicare local coverage determinations (LCD), and any other coverage requirements established by relevant payers which can be updated frequently.

Prevounce recommends that you consult with your payers, reimbursement specialists, and/or legal counsel regarding coding, coverage, and reimbursement matters.

Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding, or site of service requirements.

The coding options listed here are commonly used codes and are not intended to be an all- inclusive list. We recommend consulting your relevant manuals for appropriate coding options.

The Health Care Provider (HCP) is solely responsible for selecting the site of service and treatment modalities appropriate for the patient based on medically appropriate needs of that patient and the independent medical judgement of the HCP.