RPM Medicare Fee Schedule in 2021

“Interactive communication” and other RPM-related changes for Medicare Reimbursement in the 2021 CMS Physician Fee Schedule

medicare fee schedule

What represents an “interactive communication” in the 2021 medicare fee schedule and how does it alter CPT 99457 & 99458?

The concept of “interactive communication” raised many comments when introduced by the Centers for Medicare & Medicaid Services (CMS) in the 2021 Final Rule Physician Fee Schedule (PFS), published on December 1, 2020.

Also described as a “remote, non-face-to-face exchange,” CMS mentions the similarity to Healthcare Common Procedure Coding System (HCPCS) code G2012 (Brief Communication Technology-Based Service), defining interactive communication as:

“a real-time synchronous, two-way audio interaction that is capable of being enhanced with video or other kinds of data transmission.”

In other words, phone calls and virtual visits are considered interactive communications, but messaging is not.

The controversy with the concept was due to a discrepancy between the PFS and the Fact Sheet, which was published on the same day. While the Fact Sheet stated that some of the required 20 minutes of time associated with CPT codes 99457 and 99458 had to be interactive, the PFS stated that only interactive time would count, therefore not compensating providers going forward for time spent reviewing vitals, alerts and making care plan changes.

Some much-needed clarity and relief came on January 19, with CMS issuing a revision to make the PFS consistent with the Fact Sheet:

“We agree with commenters that our description of the required 20 minutes of time associated with CPT codes 99457 and 99458 should include care management services, as well as synchronous, real-time interactions. That is, we agree that “interactive communication” as we defined it in the CY 2021 PFS proposed rule contributes to the total time, but is not the only activity that should be included in the total time.”

Therefore, since January 1, 2021, the 20 minutes required to bill CPT 99457 and 99458 must include some time for interactive communication, but not all.

Other RPM Clarifications

The 2021 PFS brought additional clarifications to RPM (defined within the industry as Remote Patient Monitoring, but by CMS as Remote Physiologic Monitoring). Here’s a summary of the most important changes:

CPT 99454 can be billed only once per 30-day period, no matter how many devices are provided, with a minimum of 16 days of data
Referencing the CPT® 2021 Professional Codebook, CMS confirmed two facts that are well-known by the RPM community: “even when multiple medical devices are provided to a patient, the services associated with all the medical devices can be billed only once per patient per 30-day period and only when at least 16 days of data have been collected.” (2021 PFS, p. 205)

Interestingly, CMS explored the concept of shorter monitoring periods, such as eight days of monitoring within 30 days, but aside from support for the reduction in number of days, did not receive specific clinical examples, therefore keeping the requirement at 16 days. (2021 PFS, p. 215)

CPT 99453 (setup) and CPT 99454 (device) both require the use of a medical device transmitting digitally
Although not mandating FDA clearance, the 2021 PFS specifies that “the device must meet the FDA’s definition of a medical device as described in section 201(h) of the Federal, Food, Drug and Cosmetic Act (FFDCA)”. It also adds that “the medical device should digitally (that is, automatically) upload patient physiologic data (that is, data are not patient self-recorded and/or self-reported).” (2021 PFS, p. 205)

Patients with acute and chronic conditions are both eligible
“Practitioners may furnish these services to remotely collect and analyze physiologic data from patients with acute conditions as well as from patients with chronic conditions.” (2021 PFS, p. 206)

RPM can only be ordered and billed by physicians or non-physician practitioners (NPPs)
RPM services “can be ordered and billed only by physicians or NPPs who are eligible to bill Medicare for E/M services.” (2021 PFS, p. 206)

Additionally, CMS clarified that Independent Diagnostic Testing Facilities (IDTFs) are not allowed to bill for RPM, stating that “RPM services are not considered to be diagnostic tests.” (2021 PFS, p. 216)

CPT code 99091 can be furnished after the data collection period for CPT codes 99453 and 99454
“After the data collection period for CPT codes 99453 and 99454, the physiologic data that are collected and transmitted may be analyzed and interpreted as described by CPT code 99091.” (2021 PFS, p. 206)

CPT code 99091 must be furnished by a physician or qualified health professional
The definition of a qualified health professional is “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.” (2021 PFS, p. 207)

CPT codes 99457 and 99458 can be furnished by clinical staff under general supervision
As opposed to CPT code 99091 which requires the services to be furnished by a physician or qualified health professional, CMS reiterated that CPT codes 99457 and 99458 can be furnished by clinical staff under the general supervision of the physician or NPP. (2021 PFS, p. 208)

Temporary and permanent changes after the COVID-19 Public Health Emergency (PHE)

During the COVID-19 PHE After
RPM services can be provided to new patients, as well as established patients Removed: RPM can only be provided to established patients

Consent can be obtained at the time services

are furnished

Kept permanently
CPT codes 99453 and 99454 can be billed for a minimum of two days of data collection over a 30-day period, rather than the required 16 days Removed: 16 days of data within 30 days will be required

(2021 PFS, pp. 210-211)

Auxiliary personnel can furnish CPT codes 99453 and 99454
CMS finalized the proposal “to allow auxiliary personnel (which includes other individuals who are not clinical staff but are employees or leased or contracted employees) to furnish services described by CPT codes 99453 and 99454 under the general supervision of the billing physician or practitioner.” (2021 PFS, p. 210)

CPT codes 99091 and 99457 can be billed for the same patient, same period
CPT codes 99091 (collection and interpretation of physiologic data by physician or qualified health professional) and 99457 may be reported for the same patient when “reasonable and necessary,” for example, “when complex data are collected.” (2021 PFS, p. 213)

Medicare reimbursement rates for remote patient monitoring

As for the Medicare reimbursement rates, here’s a breakdown of non-facility national averages per code:

CPT Code Since Description Reimbursement
99091 2018 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, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days $56.88
99453 2019 Remote monitoring of physiologic parameter(s), (for example, weight, blood pressure, pulse oximetry, respiratory flow rate) initial; setup and patient education on equipment use. $19.19
99454 2019 Device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days. $63.16
99457 2019 Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month. $50.94
99458 2020 Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month. $41.17

Sources:

 

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