CMS Reimbursement for Remote Patient Monitoring

Up till now, reimbursement has been a key barrier in the successful, widespread adoption of remote patient monitoring (RPM). However, that has quickly changed over the last 18 months. In 2018, CMS unbundled CPT 99091. While this was a welcome step, 99091 is 16 years old and did not adequately describe RPM services nor did it provide adequate reimbursement.

Recognizing this, the Centers for Medicare & Medicaid Services (CMS) introduced three new codes for RPM services in 2019, allowing reimbursement of ~$116 per month for RPM. Furthermore, through chronic care management and a range of other codes, there are opportunities for further reimbursement under CMS. We distill these options here.

Chronic Care Remote Physiologic Monitoring

In the 2019 physician fee schedule, CMS finalized three new codes for RPM. These are:

CPT Code Description Facility Fee Non-Facility Fee
99453 Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; setup and patient education on the use of equipment $19.46 $19.46
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 $64.15 $64.15
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 $32.44 $51.54

In summary, this means that providers using RPM platforms, such as that by Current Health, can receive reimbursement. $19.46 is available under 99453 for initial set up and patient education, while a further monthly amount of $115.69, via 99454 and 99457, is available to cover the cost of the solution and at least 20 minutes of clinical time.

Requirements/considerations:

  1. Can these codes be billed incident to? Yes. CMS announced in a technical correction on March 14, 2019, that RPM could be billed as “incident to” the billing practitioners services. This crucial change allows RPM services to be delivered by auxiliary personnel but, unlike in CCM described below, those auxiliary personnel must still be under the direct supervision of the physician. In practice, this means the physician must be in the same building at the same time as the auxiliary staff delivering the RPM service, though they do not have to be in the same room.
  2. Are there geographic restrictions? No. RPM is not considered a telehealth service. Therefore there are no geographical or originating site restrictions
  3. Can the patient be at home? Yes.
  4. Do we need consent? Yes. The patient must give consent.
  5. Is there a copayment? Yes. As a Medicare Part B service, there is a 20% copayment.
  6. Does there need to be face-to-face interaction? Only if the patient is new or has not been seen by their provider for greater than one year. In that case, the provider must conduct a face-to-face visit with the patient. This visit would be reimbursable under evaluation and management (E/M) visits (CPT 99212 through 99215).

Chronic Care Management

CCM also provides a route for additional reimbursement for providers. This can be billed along with the aforementioned RPM codes. CMS has produced an excellent fact sheet on CCM reimbursement, available here.

CMS breaks CCM down into non-complex CCM and complex CCM.

Non-Complex CCM

CPT Code Description Facility Fee Non-Facility Fee
99490 Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, with the following required elements:
Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline
Comprehensive care plan established, implemented, revised, or monitored
$32.44 $42.17

Complex CCM

CPT Code Description Facility Fee Non-Facility Fee
99487 Complex chronic care management services, with the following required elements:
Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline
Establishment or substantial revision of a comprehensive care plan
Moderate or high complexity medical decision making
60 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month
$92.98 $52.98
99489 Each additional 30 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month. This is listed separately in addition to the primary code. $46.49 $26.67

99489 must be reported in conjunction with 99487. 99487 provides reimbursement for the initial 60 minutes of clinical time, while 99489 provides reimbursement for each additional 30 minutes of clinical time.

Note that a patient is either non-complex CCM or complex CCM. Never both in a given service period.

Requirements/considerations:

  1. Can this be billed in conjunction with the Chronic Care Remote Physiologic Monitoring described above? Yes. 99457 can be billed in conjunction with 99490 or 99487 but the time spent delivering these services cannot be counted towards the required time for both RPM and CCM codes for a single month. No double counting is allowed. That means that billing 99457 and 99490 would require 40 minutes of clinical time
  2. Can these codes be billed incident to? Yes. And unlike in the RPM codes described above, CMS only requires general supervision. This means the billing practitioner does not need to be in the same building at the same time as the delivery of the service.
  3. Does there need to be face-to-face interaction? Only if the patient is new or has not been seen by their provider for greater than one year. In that case, the provider must conduct a face-to-face visit with the patient. This visit would be reimbursable under evaluation and management (E/M) visits (CPT 99212 through 99215). HCPCS code G0506 (Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services) is also available can be reported once per CCM billing practitioner per CCM initiation and provides $63.43 reimbursement.
  4. Do we need consent? Yes. The patient must give consent.

CCM services can be extensive. CMS provides an excellent overview on page 6 of this fact sheet.

Given that RPM platforms, like that by Current Health, are frequently being deployed to chronically unwell patients in order to aid and improve management, there is much scope for billing on both RPM and CCM codes.

Review of Pre-Recorded Information (G2010)

G2010 is another interesting reimbursement option when using platforms that offer asynchronous image or video functionality. Current Health’s platform, for instance, allows a patient to record and send a video or images to a healthcare professional for review later on our web dashboard. G2010 provides $12.61 reimbursement for the physician to review that video/image, interpret and follow up to the patient within 24 hours. There is no frequency limitation on this code.

There are a number of requirements for billing G2010, all of which have been concisely described here by Foley & Lardner LLP.

Virtual Check-Ins (G2012)

G2012 provides one other opportunity for reimbursement. G2012 provides reimbursement of $14.78 for a brief, virtual check-in between the patient and their physician or other qualified healthcare professionals where the patient isn’t sure if symptoms require an office visit. Billing is only possible where the check-in does not lead to an office visit and where there was not a related E/M visit in the preceding 7 days. There is no frequency limitation on this code.

Platforms, like that by Current Health, allow audio and video communication between the patient and their healthcare professional with the express purpose of avoiding a utilization event. This code, therefore, could be an additional way to gain reimbursement for RPM services.

The Nixon Law Group provide an excellent break down of G2012 here.

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