Your guide to reimbursement for remote patient monitoring

Over the past several years, the Centers for Medicare and Medicaid Services (CMS) have worked to expand reimbursement codes available for remote patient monitoring (RPM) as a way to continue to help providers respond to the growing shift and demand for virtual care services.

With financial reimbursement available to support remote care, providers can use the below referenced CPT Codes for quick deployment and scaling of RPM programs. These codes provide a financial structure for physicians and qualified medical professionals to be reimbursed for the time spent and the equipment used for patient care delivered remotely.

CPT Code 99453

CPT code 99453 is a one-time practice expense reimbursing for the setup and patient education on RPM equipment. This code covers the initial setup of devices, training and education on the use of monitoring equipment, and any services needed to enroll the patient on-site. 

To bill for CPT Code 99453, the initial setup must be ordered by a physician or qualified healthcare professional (QHP). The device used in the training and set-up must be a medical device as defined by the FDA, excluding Durable Medical Equipment (DME). CPT Code 99453 allows for home-use medical devices to monitor beneficiary physiologic data that is automatically uploaded to a clinician remotely. Providers can bill for this code once every 30 days and once per episode of care. The code requires 16 days of readings be recorded during the 30-day billing period. The standard facility and non-facility rate for 99453 is $18.77.

CPT Code 99454

CPT Code 99454 covers the supply and provisioning of devices used for RPM programs, and the code is billable only once in a 30-day billing period. Specifically, this code covers the costs associated with the leasing of a home-use medical device or devices to and for the patient. Regardless of the cost of devices, physicians can be reimbursed for $62.44 for technologies provided under this code. 

Notably, CPT Code 99454 requires 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. The device used in the program must be a home-use medical device as defined by the FDA and does not include reimbursement for Durable Medical Equipment (DME). Home-use medical devices can be used daily to monitor the patient’s physiologic data and automatically uploaded to a clinician remotely.  

The physician or QHP must order the devices on behalf of the patient. The devices cannot be a part of a lease-to-own model, purchased for the patient to own, or already in the patient’s possession. Gifting devices to a patient for ongoing treatment may be in violation of federal law and result in civil monetary penalties. 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.

CPT Code 99457

CPT code 99457 is a direct monthly expense for the remote monitoring of physiologic data as part of the patient’s treatment management services. To receive reimbursement, the physician, QHP or other clinical staff must provide RPM treatment management services for at least 20 minutes per month.

CPT Code 99457 is billable once in a calendar month, regardless of the number of parameters being monitored and will be reimbursed for $51.61 (non-facility) and $32.84 (facility). 

To be eligible for reimbursement, Only a physician or QHP can enroll a beneficiary in the program. 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. CPT Code 99457 requires interactive communication with the patient and/or caregiver during the month (e.g., text, email, phone, or other electronic non-face-to-face communication/interaction). Services provided under this code may include the interpretation and review of received data and interaction with patients to coordinate and manage treatment plans by a clinician. 

Further, 99457 is not limited to treatment management services for a specific number of chronic conditions. 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. 

Providers should include all notes on beneficiary encounters, provide all information as possible (e.g. device interrogations, calls made to the patient and their duration, time reviewing data, interaction with patient records, etc.) Additionally, practitioners must obtain consent for the service and document accordingly in the patient’s record.

CPT Code 99457 is subject to requiring a “treatment plan” and not a “care plan.” This is notable as the CCM (chronic care management) codes require a comprehensive care plan to be developed and in place.

Providers should include all notes on beneficiary encounters, provide all information as possible (e.g. device interrogations, calls made to the patient and their duration, time reviewing data, interaction with patient records, etc.) Additionally, practitioners must obtain consent for the service and document accordingly in the patient’s record.

CPT Code 99458

CPT Code 99458 is an add-on code for CPT Code 99457 and cannot be billed as a standalone code. This code can be utilized for each additional 20 minutes of remote monitoring and treatment management services provided. Providers can be reimbursed $42.22 (non-facility) and $32.84 (facility) for services rendered. As with 99457, services are billable once per calendar month. Additionally, 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.

CPT Code 99091

CPT Code 99091 is the collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional. In this instance, a QHP is qualified by education, training, licensure/regulation (when applicable). The code requires a minimum of 30 minutes of interpretation and review and is billable once in a 30-day billing period.

Providers can be reimbursed $59.19 (non-facility and facility) for these services. To bill for CPT Code 99091, 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.” 

Notably, 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 related to CPT Code 99091. However, providers cannot report in conjunction with CPT Code 99457 or 99458. 

As with the aforementioned RPM codes, CPT Code 99091 requires consent from patients. Practitioners must obtain beneficiary consent for the service and document in the patient’s record. For new patients or existing patients that have been seen by the billing practitioner within a calendar year, the service must be initiated during an in-person visit.

The chart below breaks down the key differences between CPT Codes 99457 and 99091. 

To learn more about RPM related CPT codes, contact Validic to set up a call with a regulatory specialist.