What You Need to Know About 2019 Medicare CPT Codes For Remote Patient Monitoring (RPM) - 99453, 99454 and 99457

Remote Patient Monitoring

In November, 2018 CMS officially approved three new billing codes for Remote Patient Monitoring (RPM). Most telehealth industry experts agree that this is the biggest financial incentive to date in the history of digital medicine. (The average primary care physician could end up generating over $400,000 of additional revenue per physician per year). Still, most physicians, patients and even healthcare executives are either unaware or unclear of what this could mean to them.

The Opportunity for Physicians

Starting on January 1, 2019, there are three new CPT codes that cover remote patient monitoring equipment, setup and monitoring services:

• CPT code 99453: Initial setup. Pays approximately $21. “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 code 99454: Device/transmission fee. Pays approximately $69 per month. “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.”
• CPT code 99457: Monitoring and treatment. Pays approximately $53 per month for 20 minutes of time spent viewing data and communicating with patients. “Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.”

Moreover, these codes can be combined with chronic care managements services (CCM), which have been active for a few years. The combined utilization of these codes provides a mechanism that family medicine providers can use to monitor and engage with patients, and to help them more efficiently manage their chronic conditions, while getting reimbursed, providing a new mechanism that innovative and savvy physician practices may be able to use to increase their quality metrics while also increase the near term profitability of their practices.

The average primary care physician could end up generating over $400,000 of additional revenue per physician per year. This assumes that the physician extends these services to about 20% of their Medicare-covered patients. Contact us for a more detailed explanation of the numbers used in this assumption.

So, What’s Required?

In order to properly bill to these codes you must meet the following requirements:

• The patient must opt-in for the service
• Devices used must meet the definition of medical device, as defined by the FDA
• The service must be ordered by a physician or other qualified healthcare professional
• Monitoring must be greater than 16 days to be applied to a billing period
• Data must be wirelessly synced where it can be evaluated
• The data-monitoring services may be performed by the physician, by a qualified healthcare professional, or by clinical staff. Clinical staff may include, for example, RNs and medical assistants (subject to state law) 

The Big Picture: Why is CMS doing this?

While this program may seem too good to be true for primary care physicians who are used to being underpaid relative to their specialist peers, this actually makes a lot of sense from a macro level and may actually do a lot to protect the solvency of our nation. Policy makers with AMA and CMS have seen rapid growth in Medicare and Medicaid spending, totaling almost $1.3 trillion in 2017, up substantially since 2007, that is continuing to rise without some form of rapid technology-based innovation, these expenditures will continue to grow as the baby boomers continue to age, and will pile on even more to an already out-of-control national debt. CMS knows that affordable new wireless remote monitoring technologies exist that can help keep stay in their homes longer and stay out of the hospital more and initial results have been promising. These technologies have just not had enough reimbursement attached to them to make financial sense for most physicians - until now. The leaders at CMS should be commended in this case for supporting and driving innovation. While this new mechanism creates an enormous new financial opportunity for certain types of providers (e.g. primary care providers) it is expected help to reduce overall medical spending as a whole. Furthermore, innovation in this field will now accelerate even faster with more direct financial support by CMS that will drive more rapid adoption by physicians as well as more investment by technology providers.

Where do I Get the Equipment and Software?

Because this code is still very new, there are still not many options for software and equipment that can be used to meet the requirements that also fit into the workflow of primary care practices and hospitals alike. Fortunately, Pillsy has developed software that meets these needs, as we’ve been following the evolution of these codes carefully, engaging both with legal and billing experts in this field as well as directly with CMS.

We can provide you with the remote monitoring equipment, software, workflow, and expertise to get your remote monitoring program up and rolling in days or weeks. Our system works with a variety of workflows for primary care practices and hospital systems alike.

For patients, available components of our remote monitoring kits include:

• Wireless blood pressure monitoring
• Wireless scales
• Wireless medication tracking
• A mobile app for tracking recorded biometrics. As a bonus, our system also includes sophisticated medication reminder and tracking system.

The healthcare provider team gets access to web-based software that includes the following capabilities and more

• Securely viewing patient remote monitoring data in your own portal
• Flagging at risk patients who may need more outreach, so your team can reach out to the right patient at the right time
• Two-way communication with patients through our portal
• Facilitated time tracking for time spent billing, accessible while you are in the portal
• Taking notes on interactions, for compliance with CMS billing requirements
• Assigning patients to caregivers and groups for easy organization, or to compare the performance of different parts of your care team
• Direct integration with electronic health record systems is possible for enterprise partners (minimum commitments may apply)

Contact us for a free consultation and for pricing. Most of our kits are profitable in the first month, and then continue to generate revenue on an ongoing basis.

Additionally, we have options for remote monitoring call center support services, and in-home setup of equipment by partner organizations such as local home care companies.

Medicare Remote Patient Monitoring Frequently Asked Questions (FAQs)

What are the detailed definitions of these codes?

The detailed definitions of the new CPT codes are:

• CPT code 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 code 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.”
• CPT code 99457: “Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.”

How Much Time is Required to Bill CPT 99457?

At least 20 minutes per calendar month. CPT 99457 is easy to track because it is based on a calendar month, not 30-day periods, and is reimbursed on a monthly basis.

How long does it take to setup a patient with one of your wireless scales?

Your team can setup a patient with one of our wireless scales for a patient in 2-3 minutes. Our scales are cellular-based require no additional setup once they are in the home. Your patients can simply take them home and start using them - data will be automatically transferred to your portal. It's like magic! Nothing else is required.  However, there are additional options for equipment that you can provide that can be connected to other devices (e.g. Bluetooth).

What Type of Technology Qualifies Under the New RPM Codes?

Many have argued that CMS should cover Fitbits, Holter-Monitors, and other types of equipment. Unfortunately, there is currently no clear guidance on this. CMS does plan to issue additional guidance on these issues. In the meantime, the safest bet is to make sure that you use the defined equipment (e.g. wireless scales, wireless blood pressure cuffs, pulse oximetry, etc.). Pillsy’s kits include equipment that is already clearly defined on this list. We also provide medication reminder and monitoring devices a bonus item that may help to improve outcomes, and to prevent issues from happening before they are recorded by these devices.

Can the Patient be at Home for RPM Reimbursement?

Yes, the patient can be at home. In fact, this is the intention behind the code.

Must the Patient be in a Rural Area for RPM Reimbursement?

No, the patient need not be located in a rural area or any specific geographical area. CMS does not consider RPM to be a Medicare telehealth service. Instead, CMS pays for RPM services under the same conditions as in-person physicians’ services, with no additional requirements related to their geography.

Does RPM Require an In-Person Exam or Interactive Audio-Video Connection for Ongoing Communication?

No, RPM services do not require the use of interactive video connection. However, for new patients or patients who have not been seen by the practitioner within one year, the practitioner must first conduct a face-to-face visit with the patient prior to billing for RPM.

Who Can Deliver RPM Services?

According to the Foley law blog, “CPT 99457 allows RPM services to be performed by the physician, qualified healthcare professional, or clinical staff. Clinical staff includes, for example, RNs and medical assistants (subject to state law scope of practice and state law supervision requirements). The inclusion of “clinical staff” is the most significant differentiator from CPT 99091, as that code is limited only to “physicians and qualified health care professionals.” All practitioners must practice in accordance with applicable state law and scope of practice laws. The term “other qualified healthcare professionals” used in CPT 99457 is a defined term, and that definition can be found in the CPT Codebook.”

We have had additional legal input. We cannot provide you with legal advice but you may contact us if you’d like to discuss.

Must the Patient Give Consent to RPM Services?

Yes, the patient must give consent. This should be documented in their medical record.

Can RPM Also Be Billed with Chronic Care Management (CCM)?

Yes. However, the time spent performing RPM analysis may not be applied towards the same time being billed to CCM (e.g. no double-counting of time).

Can your system be integrated into my existing electronic health record system?

Yes. We're working on integrating data directly into leading electronic health record systems.

What Are Some Other Online Resources:

Medicare Remote Patient Monitoring Reimbursement FAQs: Everything You Need to Know About Chronic Care Remote Physiologic Monitoring Codes

Medicare’s New Chronic Care Remote Physiologic Monitoring Codes: Everything You Need to Know