Broadly speaking, billing is complex and challenging for healthcare organizations. Keeping track of complicated coding systems and changes to regulatory requirements and reimbursement rates is an ongoing necessity to avoid errors that may lead to payment delays and claim denials. Critical mistakes can further end in financial losses that are highly detrimental in a competitive industry.
In the case of remote patient monitoring (RPM), which can be used both as a standalone solution and an essential part of other patient care models, keeping up with the intricacies of billing is particularly tricky. Each year, the Centers for Medicare & Medicaid Services (CMS) releases new rulings for how, when, and by whom RPM can be billed.
CMS’ 2024 Physician Fee Schedule final rule introduced several updates and changes, including the landmark ruling that federally qualified health centers (FQHCs) and rural health centers (RHCs) can now bill for RPM services as well as remote therapeutic monitoring (RTM).
This review of RPM billing includes an explanation of the basics, including RPM codes, and a full breakdown of the 2024 final rule. It’s designed to catch healthcare organizations up on everything they need to know to correctly bill for services.
Understanding the basics of remote patient monitoring reimbursement
Providing effective care to patients with chronic and acute conditions is accomplished through numerous care management services and models, and RPM serves as the basis for several. RPM supports hospital-at-home programs, which offer hospital-level service in a patient’s home or place of residence; transitional care management (TCM) and principal care management (PCM), both post-discharge care models for acute patients; and chronic care management (CCM), used for the treatment of patients with two or more chronic conditions. RPM can be “coupled” with some of these service models during billing and reimbursement, but it has its own billing codes covering specific timelines within which services are delivered.
Providers submitting an RPM claim must be able to report the CPT codes for the programs they’re managing, in addition to the ICD-10 codes tied to the conditions managed, the data and place of service, and their National Provider Identified (NPI) number.
Need a primer? Read more about the difference between RPM and telehealth, and why it matters.
It’s important to use RPM billing codes precisely and in a timely fashion. Doing so provides reimbursement opportunities as well as the chance to enhance patient care capabilities and bolster a clinical organization’s business viability with expanded capacity.
How do remote patient monitoring CPT codes work?
First introduced by CMS in 2018, remote patient monitoring CPT codes outline the who, what, when, where, and why of RPM billing and reimbursement. They include a standalone code as well as several others that work together as an RPM billing sequence:
• CPT code 99091 is its own separate entity, “unbundled” from the codes below and usually ineligible for use in combination with any of them. It includes 30 minutes per month of clinical time between a patient and a physician or qualified healthcare provider (QHP), and requires at least one instance of communication, which can be done remotely (i.e., a call, video visit or email exchange, but not text).
• CPT code 99453 covers the initial time spent with the patient in the program and/or device setup and education. It’s valid once per episode of clinical care (the time from service activation to when treatment ends), even if the patient is cared for by more than one clinician or uses a number of different RPM devices.
• CPT code 99454 covers the time spent in remote monitoring of the patient on a monthly basis — specifically, the provision and use of the medical devices that remotely monitor and collect patient data. 99454 must be billed as a follow-up to 99453, and it requires that data be collected over at least 16 days of a 30-day period.
• CPT code 99457 covers the initial treatment management of the patient. This includes reimbursement for the first 20 minutes of time spent with a patient per month. As with code 99091, these sessions can be conducted remotely, possibly including a telephone or video connection — and, in some instances, text communication is allowed.
• CPT code 99458 is an add-on to code 99457 — which means that it can only be billed as a follow-up, and not as its own standalone code. It covers additional 20-minute periods of time spent in management of the patient, with a maximum of 60 minutes total per month.
Each of these RPM codes is considered an evaluation and management (E/M) service, which typically can be billed by only physicians and other QHPs like nurse practitioners and physician assistants. However, other clinicians operating under the direct supervision of the primary doctor or QHP may also administer services for 99453, 99454, 99457, and 99458.
Learn more: Take a Closer Look at Current RPM Billing Codes
CMS final rule for 2024: What you need to know
This year’s CMS final rule contains several updates and changes to remote patient monitoring reimbursement and RPM billing that providers must know, starting with a critical expansion of the facilities that can bill for RPM and RTM.
FQHCs and RHCs can now bill for RPM services.
In one of the most welcome clarifications of its 2024 proposed rule, CMS states in its final rule that FQHCs and RHCs can receive payment for RPM (and RTM) outside of RHC all-inclusive rates and FQHC per-visit payments. The general management code HCPCS G0511, which already included services like CCM, TCM, and BHI, is being expanded to include RTM and RPM billing. Though the reimbursement amount has been lowered, G0511 can be billed multiple times for the same patient per month for all subcategory codes. This means that, if a patient is in both an RPM and CCM program, FQHCs and RHCs can bill Medicare for each one in the same month, so long as requirements are met for each service.
Practitioners must collect at least 16 days of data per 30-day period.
In its ruling, CMS clarified which remote monitoring codes require at least 16 days of data collection in a 30-day period and which do not. Previously, it stated that RPM and RTM setup and device codes (CPT codes 99453, 98976, 99454, 98977, and 98978) required at least 16 days of data collection. However, it was unclear as to whether the 16-day requirement applied to the four treatment management codes (CPT codes 99457, 99458, 98980, and 98981). CMS affirmed that it does not.
RPM can, once again, only be furnished to “established patients” – though RTM doesn’t have the same requirement.
During the PHE, restrictions around who could receive RPM services were temporarily loosened. Starting from the official PHE end date of May 11, 2023, however, CMS is reinstating the requirement that only “established patients” are eligible. (Established patients are those who have been evaluated and have a treatment plan in place.) This does come with a caveat: Medicare patients who received initial RPM services during the PHE will be considered established patients. Notably, RTM services don’t carry the same requirement as RPM.
Only one practitioner can bill Medicare for RPM services.
Regardless of how many RPM devices a patient is provided with, the services associated with them can only be billed by one practitioner, once per patient, per 30-day period. And no RPM billing can be completed until at least 16 days of data are collected within that period. CMS also cautions that remotely monitored monthly services should only be billed when reasonable and necessary.
RPM (or RTM) can be billed alongside other services.
To provide practitioners ample flexibility when selecting the right combination of care management services for a patient, CMS is allowing concurrent billing of RPM or RTM (though not both) with the following care management services: CCM, TCM, behavioral health integration (BHI), PCM, and chronic pain management (CPM). The time and effort involved in care provision for these services, however, cannot be counted twice.
There are restrictions around RTM and RPM billing during a global surgery period.
When a doctor performs a surgery within a global billing period, they receive a single payment that covers follow-up services during that time. During this period, the doctor cannot separately bill Medicare for RPM or RTM services. However, this restriction only applies to doctors receiving the global service payment. Other practitioners, like therapists, who didn’t perform the global procedure, can offer RPM or RTM services during the global period.
Additionally, if a patient is already receiving RPM or RTM services during a global period, a practitioner can continue providing these services, and Medicare will pay separately. The key is that the monitoring services must be unrelated to the global procedure’s diagnosis and should address a different episode of care.
Got questions on RPM codes and billing? We’ve got you covered.
Remote patient monitoring reimbursement will continue to evolve with each new final rule, and with it, more questions are sure to surface. If you’re looking for even more information on RPM billing, we’re standing by to help! Contact us today to get in touch with a CareSimple expert and learn more about our solutions.