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CMS Amendments to Remote Patient Monitoring Rules 2021

CMS Amendments to Remote Patient Monitoring Rules 2021

CMS recently updated its guidelines on Medicare requirements for remote physiologic monitoring (RPM) services for the year 2021. The adjustment took effect on January 1, 2021, and the prelude statement in the Medicare Physician Fee Schedule (PFS) Final Rule has been updated, which PFS was previously issued on December 1, 2020.

Remote Patient Monitoring (RPM) refers to a process of gathering and analysis of patient physiologic data (parameters) used to further establish and implement a treatment plan for chronic and/or acute health illness or condition. It refers to the “periodic, asynchronous, or continuous monitoring and transmission of vital signs such as weight, blood pressure, oxygen saturation, glucose levels, heart rate, or heart rhythm.” 

Five Primary Medicare RPM codes:  99453, 99454, 99457, 99458 and 99091

Remote Patient Monitoring (RPM) Current Procedural Terminology (CPT) Service Codes

CPT Code 99453

CPT code 99453 is a one-time practice charge that reimburses for RPM equipment setup and patient instruction. The initial configuration of devices, training, and teaching on the usage of monitoring equipment, and any services required to enroll the patient on-site are all covered by this code. To bill for CPT Code 99453, a physician or qualified healthcare professional must order the initial setup under a Qualified Health Plan (QHP). The device utilized in the training and setup must be a medical device cleared by the FDA, excluding Durable Medical Equipment (DME), which is a long-lasting medical equipment intended to last longer than a single use, and sometimes for months or even years. Also, these devices are home-use medical devices reimbursable under CPT Code 99453 that can monitor the patient’s physiologic data and send it to a doctor remotely. This code can be billed only once after 30 days and may only be billed once every one episode of service by providers to the patient. During the 30-day billing cycle, the code to be documented needs 16 days of readings. CPT Code 99453 has a standard facility and non-facility charge of $20.27 (based on CMS Physician Fee Schedule 2021)

 CPT Code 99454

Only one claim per 30-day billing cycle can be submitted for CPT Code 99454, which covers the supply and provisioning of RPM devices. This code covers explicitly the costs associated with leasing a home-use medical device(s) to and for the patient. Physicians can be reimbursed for approximately $67.10 for technologies provided under this code, regardless of the device cost. CPT Code 99454, in particular, requires the device to submit at least 16 days of readings of the patient’s physiological parameters within 30 days. To be eligible for compensation, the doctor must have at least 16 days’ worth of patient readings. The device must also be a home-use medical device as cleared by the FDA, and it does not include payment for DME. Medical devices for home use can be used daily to track a patient’s physiologic data and send it to a doctor over the internet. The physician or qualified health professional must place the order on the patient’s behalf. The devices must NOT be part of a lease-to-own program, acquired for the patient’s use, or already in the patient’s possession. Providing a patient with a device for continued treatment may constitute a violation of federal law, resulting in civil monetary penalties. The provider or QHP must provide invoices for the cost of the equipment and, if applicable, services linked to the equipment, such as kitting, cleaning, and so on, as part of a CPT Code 99454 audit.

Remote Patient Monitoring (RPM) Current Procedural Terminology (CPT) Management Codes

CPT Code 99457

CPT code 99457 includes remote monitoring of physiologic data as a component of the patient’s treatment management services on a month-to-month basis.  To meet the requirements for RPM treatment management services, a physician, Qualified Health Physician (QHP), or other clinical staff member must allocate at least 20 minutes each month in providing treatment management services.  CPT Code 99457 is billable once each calendar month, regardless of the number of parameters monitored, and reimbursable for $51.61 (non-facility) and $32.84 (facility), respectively.

Only a physician or a qualified health plan (QHP) can enroll a patient in the program and receive reimbursement. When critical patient care is provided by clinical staff, the RPM services can be billed as “incident to” under general supervision, which means the physician does not need to be on-site.  Throughout the whole month, CPT Code 99457 usually requires interactive communication with patients and the primary caregiver. Interpretation and assessment of received data, as well as engagement with patients to organize and manage treatment programs, are examples of services given under this code. Additionally, 99457 is not limited to treatment management services for a particular set of chronic diseases: arthritis; cardiovascular disease, e.g., heart attacks and stroke; cancer e.g., breast and colon cancer; diabetes; epilepsy and seizures; obesity; and oral health problems. Whenever a patient is currently enrolled in multiple programs supervised by different physicians for various diseases, each provider can bill separately for each program; however, they cannot share equipment reimbursement for the same or equivalent device. All notes on beneficiary encounters should be included and as much information as possible should be provided. Moreover, practitioners must seek the patient’s consent for the service and document it in the patient’s record.

CPT Code 99457 is subject to a “treatment plan” requirement rather than a “care plan.” A treatment plan is designed for a particular patient’s needs, and it does not always have a system-wide effect on patient care.  A system-level action plan or “care plan” is a plan that will more likely prevent future occurrences because it focuses on systems, practices, and procedures rather than individuals. This billing requirement is significant since the CCM (chronic care management) guidelines demand the creation and implementation of a comprehensive care plan.  Providers should include any notes on beneficiary interactions, such as calls made to the patient and the duration of those conversations, time spent on data analysis, and others. Practitioners must also obtain consent for the service and document it in the patient’s record.

CPT Code 99091

CPT Code 99091 requires the collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) by the patient and/or caregiver and digitally stored and/or transmitted to the physician or other qualified health care professional. A QHP is qualified through education, training, and licensure/regulation (when applicable) in this particular instance. The code generally requires a minimum of 30 minutes of interpretation and review and is billable once every 30 days. For these services, providers can be compensated at $59.19 (non-facility and facility), but this depends on the location. The initial provider service must occur at the physician’s office or other applicable venues in order to charge under CPT Code 99091. Furthermore, only a physician or qualified health professional (QHP) may provide these services, as opposed to 99457, which allows a clinical staff member to give treatments “incident to.” It is worth noting that the data from devices used in conjunction with 99091 does not have to come from an FDA-approved device. To fulfill the requirements for CPT Code 99091, there is no specific number of conditions that must be monitored. Providers, on the other hand, cannot report this together with CPT Codes 99457 or 99458.

CPT Code 99091, like with the above-mentioned RPM codes, requires patient consent. Beneficiary consent for the service must be obtained and documented in the patient’s record. The service must be started during an in-person visit for new patients or existing patients who have seen the billing specialist within the last calendar year.

Remote Patient Monitoring Rules In 2021

CMS recently updated its guidelines on Medicare requirements for remote physiologic monitoring (RPM) services for the year 2021. The adjustment took effect on January 1, 2021, and the prelude statement in the Medicare Physician Fee Schedule (PFS) Final Rule has been updated, which PFS was previously issued on December 1, 2020. It includes text that was accidentally removed from the Final Rule and summaries and responses to some public concerns.

Here is a rundown of the new changes:

  •  Twenty minutes includes, but is not limited to, “interactive communication” with the patient.

The specified 20 minutes associated with CPT codes 99457 and 99458 incorporate care administration, as well as synchronous, real-time intuition with understanding. CMS clarified the “interactive communication” component contributes to the entire time but is not the sole activity that can be included when calculating the 20 minutes per month.  Another method is the 20-minutes of intra-service work related with CPT codes 99457 and 99458, which includes a practitioner’s time spent in “interactive communication” and non-face-to-face care regimens within the month.

  • One physician, per patient, per period, on RPM billing

 Only one practitioner can charge CPT codes 99453 and 99454 for 30 days and only when at least 16 days of information has been collected on at least one medical device. “Even in cases where multiple medical devices are provided to a patient,” CMS explained, only one practitioner can bill for all medical device services, and only once per patient, every 30 days, and only after at least 16 days of data have been collected.” To be reimbursed under the Medicare Program, the services must, of course, be reasonable and necessary.

 Understand the Remote Monitoring Codes

According to CMS, RPM-related codes are not restricted to CPT codes 99091, 99453, 9454, 94557, and 99458.  There are more precise invoicing codes enabling remote monitoring (for example, CPT code 95250 for continuous glucose monitoring and CPT codes 99473 and 99474 for self-measured blood pressure monitoring). When a more particular code for describing a service is available, the CPT Handbook requires that the more specific code be billed. When it comes to remote monitoring, there are usually two sides to it. The first component is data collection and monitoring, while the second element is treatment and management of the problems tracked by the data. To guarantee appropriate coding and claim submission, practitioners should consult their certified billing and coding professionals.

 The Billing Regulations of Medicare

To be reimbursed for RPM patient education and device supply, physicians need to follow Medicare’s billing requirements. In the CMS-1693-F final rule, CMS did not indicate the exact forms of technology that pertain to code 99454; nonetheless, CMS has specified that the device must be a “medical device as defined by the FDA.” While Medicare does not need the device to be FDA “approved” or “certified,” a provider’s specific usage of an RPM device with patients may necessitate FDA approval. To evaluate FDA compliance requirements and if the device fulfills the FDA’s criteria, the provider should seek legal guidance.

CPT Code 99453 billing shall be made even if, for instance, two or more Medicare beneficiaries get initial setup and patient education on the use of the RPM device and equipment on the same day from a trained healthcare provider. CMS has not issued billing guidance in this case, and healthcare sector experts cannot rely on Medicare’s telehealth rules because RPM is not considered a telehealth service by CMS. “Initial; setup and patient teaching on the use of equipment,” according to code 99453. As with other non-RPM procedure codes, the code definition does not specify “individual” or “group.”

Many healthcare industry experts agree that if two or more patients get code 99453 services in a group simultaneously from the same competent healthcare professional and all other code conditions are met, the billing provider may be entitled to submit a separate claim for each of the patients. RPM billing providers should contact their region’s Medicare Administrative Contractor and inquire about how to bill in this case.

CPT Code 99454 – One Patient, Two Different RPM devices Two Different Physicians

If a single beneficiary is treated with two separate RPM devices by two different doctors in two separate practice settings, regardless of whether the beneficiary utilizes one RPM device or numerous devices, CPT CODE 99454 CAN ONLY BE BILLED ONCE PER 30 DAYS PER BENEFICIARY. As a result, even if a patient is given a glucometer and a blood pressure cuff for use in RPM and each device fits all of the standards for billing code 99454, the code may only be paid once per 30 days for that beneficiary. The same answer applies if the two physicians work in two different practice settings or the same practice group.

If a single beneficiary receives RPM services from more than one physician in two or more different practices during the same month/same episode of treatment, the four RPM codes may be covered if:

  1. The beneficiary is a long-term patient of each physician and has given his permission for each physician in each practice to provide RPM services.
  2. The physicians are keeping track of various physiological parameters for this patient.
  3. The time taken for the time-based 99457 and 99458 RPM codes cannot be duplicated by the two doctors.
  4. The monitoring of the parameters is considered medically necessary.

Providing RPM Services And Obtaining Consent

 CPT codes 99457 and 99458 can be provided by a physician or other qualified healthcare professional or by clinical personnel under the general direction of the physician. In contrast, CPT code 99091 can ONLY be provided by a physician or other qualified healthcare professional. The CPT Codebook defines a physician or other qualified healthcare professional as “an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.” A “physician or other qualified healthcare professional” is a person practitioner for whom the standard of practice and Medicare benefit category includes the service is known to as a “physician or other qualified healthcare professional” and may bill Medicare independently for the service when referring to a specific service indicated by a CPT code for Medicare purposes.

According to the CPT Codebook, a clinical staff member is “a person who works under the supervision of a physician or other qualified healthcare professional and is permitted by law, regulation, and facility policy to perform or assist in the performance of a specified professional service but does not individually report that professional service.” CMS finalized its proposal in the 2021 Final Rule to allow auxiliary people to provide services defined by CPT codes 99453 and 99454 under the general supervision of the billing physician or practitioner, in addition to clinical staff. Other individuals who are not clinical staff but are employees, leased or contractual employees, are referred to as auxiliary workers. CMS took this stance because “the CPT code descriptors do not require that clinical professionals must execute RPM services,” according to the proposed rule for 2021. According to CMS, RPM services are never considered diagnostic tests; thus, they can’t be provided and invoiced by an Independent Diagnostic Testing Facility on a physician’s prescription.

Now, when RPM services are provided, consent to RPM can be requested. Individuals under contract with the billing physician or a certified healthcare professional can get consent.

Interactive Communication

In the 2021 Final Rule, CMS said that “interactive communication” for CPT codes 99457 and 99458 entails a real-time synchronous, two-way audio engagement that can be enhanced by video or other forms of data transfer. In the proposed rule for 2021, CMS stated that at least 20 minutes of interactive conversation time with the patient must be spent over the course of a calendar month, rather than being included in the overall 20 minutes of RPM service.

In its initial August 2020 interpretation, CMS caused an outrage and discord among the industrial players, including comments of the American Medical Association that developed the RPM codes and commented: “The time in the Description for codes 99457 and 99458 was for all elements relating to remote monitoring and is not intended to be confined to remote physiological monitoring.”

CMS issued a Fact Sheet on December 1, 2020, as a companion summarizing the key changes in the 2021 Final Rule, agreeing with the AMA’s position that the 20-minutes can include time for providing care management services as well as the required interactive communication. CMS stated: “We clarified that the term “interactive communication” as used in CPT codes 99457 and 99458 refers to an intimate conversation that includes synchronous, bidirectional interactions that may be enhanced by video or other data types as defined in the G2012 HCPCS code. Additionally, we explained that the 20 minutes required to bill for CPT codes 99457 and 99458 services can include both time spent providing care management services and time spent engaging in the requisite interactive communication.”

According to the language in the Fact Sheet, CMS, therefore, rejected its plan to mandate a full 20 minutes of patient interaction. However, this clarification cannot be found in the Advance Copy of the Final CMS 2021 rule and seems to conflict directly with the fact sheet of CMS.

The Practice Expense Codes Used For RPM

The RPM entire procedure, according to CMS, typically starts with the two-practice expense-only codes (99453 and 99454). These codes are incredibly valuable since they cover clinical staff time, supplies, and equipment, including the medical equipment in a typical remote monitoring situation. CPT code 99453 is valued to reflect time spent by clinical staff instructing a patient and/or caregiver on the proper use of one or more medical devices. CPT code 99454 is valued for the inclusion of a patient supply of medical devices and repeated monitoring programming of a medical device. The medical device or devices provided to the patient and utilized to collect physiologic data are considered equipment, according to CMS, and are thus direct practice expense inputs for the code.

Takeaway

Yet even with some remaining ambiguities, the CMS final rule strengthens RPM services’ ability to drive additional revenue and improve the quality of care. We will continue to update you with any CMS changes in their rules and policies.

RPM CPT Category 99453 99454 99457 99458 99091
Service Codes Service codes Management codes Management codes  
  A physician or Qualified Healthcare Professional A Physician or Qualified Healthcare Professional A Physician, Qualified Health Physician (QHP), or other clinical staff member Only a Physician or QHP can enroll a beneficiary in the program The physician or other qualified health care professional
Reimbursement $19.19 $63.16 $50.94 $41.17 $56.88
When to bill Once every 30 days and once per episode of care. the code is billable only once in a 30-day billing period.   least 16 days of device readings submitted by the patient within the 30-day period. Meaning, to receive reimbursement, the physician must have at least 16 days’ worth of readings from the patient. At least 16 days of device readings submitted by the patient within the 30-day period. Meaning, to receive reimbursement, the physician must have at least 16 days’ worth of readings from the patient.   billable once in a calendar month, regardless of the number of parameters being monitored This code can be utilized for each additional 20 minutes of remote monitoring and treatment management services provided. The initial provider service must occur in the physician’s office or other applicable sites. Additionally, only a physician or QHP may perform these services, distinguishing it significantly from 99457 in which a clinical staff member can provide services “incident to.”
Other Requirements The code requires 16 days of readings be recorded during the 30-day billing period. As part of an audit for CPT Code 99454, the provider or QHP needs to provide invoices for the cost of the devices and, if relevant, services related to the devices, such kitting, cleaning, etc.   Requires interactive communication with the patient and/or caregiver during the month.   Services can be billed as “incident to” under general supervision – meaning the physician does not need to be on-site when integral patient services are provided by clinical staff.   If the patient is enrolled in multiple programs by multiple physicians for varying conditions, each provider can bill separately for each program; however, they cannot share equipment reimbursement for the same or similar device.   practitioners must obtain consent for the service and document accordingly in the patient’s record.   May be used in conjunction with CCCM, CCM, TCM, PCM, and BHI care management services codes An add-on code for CPT Code 99457 and cannot be billed as a standalone code.   to be billable, the initial provider encounter must occur in the physician’s office or another applicable site of the practitioner’s normal office location.   As with 99457, services are billable once per calendar month The data from devices used in conjunction with 99091 do not have to be from a device as defined by the FDA.   There is no set number of conditions that must be monitored to meet criteria.   providers cannot report in conjunction with CPT Code 99457 or 99458.   May be used in conjunction with CCCM, CCM, TCM, PCM, and BHI care management services codes  

To know more about Remote Patient Monitoring, click this Comprehensive Guide

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