Whether your practice is already delivering or is planning to deliver RPM services to Medicare and/or Medicaid patients this year, you must understand the CMS rules for remote patient monitoring services in 2020. Without this knowledge, you run the risk of not getting paid appropriately for remote patient monitoring by CMS (Centers for Medicare & Medicaid Services) and possibly running afoul of requirements that can jeopardize your reimbursement and lead to regulatory headaches.
To help ensure you receive appropriate and timely payments for remote patient monitoring from CMS and avoid legal scrutiny for RPM services, here are three key things to know.
1. CMS coding and billing rules for remote patient monitoring in 2020
Over the past few years, CMS has significantly revised its coverage of RPM services through the overhaul of CPT codes and an increase in payment for remote physiological monitoring services. These changes were confirmed in Medicare physician fee schedule final rules and turned RPM into one of the most lucrative Medicare care management programs.
Let's first take a quick look at the CPT codes you should use to bill remote patient monitoring to CMS, and then we will summarize how these codes can translate into a consistent and financially worthwhile revenue generator for practices.
Remote Physiological Monitoring CPT Codes
Four essential CPT codes cover remote patient monitoring. They are as follows:
CPT 99453
The description of CPT 99453 is: "Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment"
CPT 99454
The description of CPT 99454 is: "Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days"
CPT 99457
The description of CPT 99457 is: "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
The description of CPT 99458 is: "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"
CPT 99091
We stated that there were four essential RPM CPT codes, which are identified above. There is a fifth CPT code that's worth knowing about because it's a code you likely want to avoid: CPT 99091. This was the initial code that practices used to bill for remote patient monitoring. While CPT 99091 is still accepted by CMS when billing for remote patient monitoring in 2020, it is no longer advisable to do so since the aforementioned RPM codes represent better options for the vast majority of situations.
For a deeper dive into CPT coding for remote patient monitoring, download the Prevounce Remote Patient Monitoring Billing Guide.
Payment for remote patient monitoring from CMS
How much can you expect to get paid for remote physiological monitoring? Let's break this down. For an individual patient, initial enrollment (CPT 99453) generates a single payment from Medicare of about $21.
After that, practices providing ongoing remote patient monitoring services can bill CMS on a monthly basis. There is a base monthly RPM payment (CPT 99454) that earns a practice around $64. The first 20 minutes of care management services, covered under CPT 99457, averages a payment of $55. Most patients will require no more than 20 minutes of clinical staff time per month. This means that a practice would generate about $120 in reimbursement per patient per month. If this "minimum" amount of services is provided to 50 patients, a practice will receive about $72,000 in Medicare reimbursement every 12 months — not too shabby!
For patients who require more than 20 minutes of care management services during an RPM session, practices can submit CPT 99458, which averages a payment of $44, to cover an additional 20 minutes of care management services. If patients need more than 40 minutes of care management services, practices can bill CPT 99458 a final time and get paid the same $44 rate. Practices cannot bill more than 60 minutes of care management services.
Reimbursement rates from private payers vary, but many base what they will pay on CMS's figures.
2. Changes to remote patient monitoring CMS rules due to COVID-19
Since we're discussing CMS rules for remote patient monitoring in 2020, we must cover how COVID-19 affected these rules. In the days and weeks that followed the declaration of COVID-19 as a pandemic and national health emergency, federal and state governments as well as private payers announced changes to rules intended to help improve access to care (i.e., reduce barriers to care). This change allowed patients who were under the restrictions of stay-at-home orders to reduce contact with others and to maintain social distancing.
On the healthcare delivery side, one of the more significant changes concerned CMS temporarily relaxing and expanding telehealth rules. Remote patient monitoring is a telehealth delivery system. In May, CMS issued two Medicare physician fee schedule interim final rules that revised payment policies and Medicare payment rates. Five of the most noteworthy changes to RPM policies in these interim final rules are as follows:
- Removal of the requirement that there must be an established patient-practitioner relationship to initiate the delivery of RPM services. New and established patients can receive RPM services.
- For CPT 99454, modification of the number of days that data must be collected from the required 16 days to fewer than 16 days in a 30-day period if the patient has or is expected to have COVID-19 and other code requirements are met.
- Clarification that RPM services can be used for physiologic monitoring of patients with acute and/or chronic conditions.
- Modification of the requirement that consent must be obtained prior to providing an initial remote physiological monitoring service. Rather, practitioners can now obtain consent at the time services are provided and by individuals providing RPM services under contract to the ordering physician or qualified healthcare professional.
- Confirmation that RPM services can be furnished under general supervision.
CMS published a helpful resource answering frequently asked questions on Medicare fee-for-service billing that includes some questions about RPM. Access it here.
3. Proposed remote patient monitoring rules from CMS for 2021
In mid-July, CMS released its 2021 Medicare physician fee schedule proposed rule. Within it were a number of proposals that, if finalized, would affect remote patient monitoring (RPM). Some of the proposed changes are fairly significant — so much so that we hosted a webinar focusing solely on the proposed RPM changes, which you can access here.
The changes touch on a wide variety of matters, including the RPM CPT codes, what technologies are acceptable as billable communication solutions, which of the interim rules would and would not become permanent rules, requirements for the medical devices supplied to patients, and whether RPM services are considered to be evaluation and management (E/M) services. To review a summary of the most significant proposals and learn about where CMS is seeking feedback, read our blog on the proposed rule.
Keeping Current With Remote Patient Monitoring Developments from CMS
RPM is a fairly new service, which is why we are seeing it undergo ongoing — and, at times, significant — regulatory changes. At Prevounce, we pride ourselves on remaining current with compliance to help ensure our RPM clients never need to worry about our remote patient monitoring system failing to meet evolving requirements. As CMS announces changes to RPM, whether they are proposed or final, we will be analyzing them on this blog and in webinars. Follow Prevounce on LinkedIn and Twitter to be sure you never miss our coverage.
