2019 Medicare Physician Fee Schedule and Quality Payment Program – CMS Final Rule – CPT Codes 99453, 99454, and 99457 – Everything You Need to Know – 2019
CMS has issued a final rule with three new codes for RPM services, retitled “Chronic Care Remote Physiologic Monitoring,” which do a far better job reflecting how providers can more effectively and efficiently use RPM technology to monitor and manage patient care needs, including chronic care management. These three codes go live January 1, 2019. These codes incentivize providers to effectively and efficiently use RPM technology to monitor and manage patient care needs.
CMS’ explanation for its bold, new rule: “We now recognize that advances in communication technology have changed patients’ and practitioners’ expectations regarding the quantity and quality of information that can be conveyed via communication technology. From the ubiquity of synchronous, audio/video applications to the increased use of patient-facing health portals, a broader range of services can be furnished by health care professionals via communication technology as compared to 20 years ago.”
Medicare Remote Patient Monitoring Frequently Asked Questions (FAQs)
- Does Medicare Already Cover Remote Patient Monitoring?
Yes. Even before the new codes, Medicare already offered separate reimbursement for RPM services billed under CPT code 99091. That service is defined as 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, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time.” It went live for the first time on January 1, 2018.
- Why Did CMS Create the New RPM Codes?
While industry advocates generally applauded CMS for activating CPT 99091, they recognized how that code fails to optimally describe how RPM services are furnished using current technology and staffing models. This failure may be due to the fact that CPT 99091 is 16 years old and had never before been a separately payable service. (It is an older code CMS “unbundled” and designated as a separately-payable service.) Indeed, the AMA’s CPT Editorial Panel developed and finalized the three new RPM codes in late 2017. These are the codes CMS finalized effective in 2019. The new codes do a far better job in accurately reflecting contemporary RPM services.
- What Are the New RPM Codes?
The new Chronic Care Remote Physiologic Monitoring codes are:
- CPT code 99453: “Remote monitoring of physiologic parameter(s) (e.g, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment.” The Medicare payment for these services is $19.46.
- CPT code 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.” The Medicare payment for these services is $64.15.
- CPT code 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.” The Medicare payment for these services is $51.54.
- How Much Time is Required to Bill CPT 99457?
At least 20 minutes per calendar month. This differs from CPT 99091, which requires at least 30 minutes per 30-day period. CPT 99457 is much easier to track because it is based on a calendar month, not 30-day periods. This will more easily align with recordkeeping and claims submission, as CPT 99457 is reimbursed on a monthly basis.
- What Type of Technology Qualifies Under the New RPM Codes?
Many advocates asked CMS to clarify the kinds of technology covered under CPT codes 99453, 99454, and 99457. Some groups gave examples of the kinds of technology they believe these codes should cover, such as software applications that could be integrated into a beneficiary’s smartphone, Holter-Monitors, Fitbits, or artificial intelligence messaging. Other examples included behavioral health data and data from wellness applications, or results of patients’ self-care tasks. Unfortunately, CMS did not offer any specifics in the final rule on what technology qualifies, but CMS does plan to issue forthcoming guidance to help inform practitioners and stakeholders on these issues. This may likely be in the form of a CMS MLN article or Q&A.
- Who Can Deliver RPM Services?
CPT 99457 allows RPM services to be performed by the physician, qualified healthcare professional, or clinical staff. Clinical staff includes, for example, RNs and medical assistants (subject to state law scope of practice and state law supervision requirements). The inclusion of “clinical staff” is the most significant differentiator from CPT 99091, as that code is limited only to “physicians and qualified health care professionals.” All practitioners must practice in accordance with applicable state law and scope of practice laws. The term “other qualified healthcare professionals” used in CPT 99457 is a defined term, and that definition can be found in the CPT Codebook.
- Can RPM (CPT 99459) Be Billed “Incident To”? What Supervision Level is Required?
CMS stated that CPT code 99457 describes professional time and “therefore cannot be furnished by auxiliary personnel incident to a practitioner’s professional services.”
This position is notably different from how CMS chose to deal with Chronic Care Management (CCM) services (CPT 99487, 99489, and 99490). For those CCM Services, CMS made an exception allowing incident to billing under general supervision. (“CCM services that are not provided personally by the billing practitioner are provided by clinical staff under the direction of the billing practitioner on an “incident to” basis (as an integral part of services provided by the billing practitioner), subject to applicable State law, licensure, and scope of practice. The clinical staff are either employees or working under contract to the billing practitioner whom Medicare directly pays for CCM.”)
In light of how CMS treated CCM services, it is difficult to understand CMS’ dissimilar treatment of CPT 99457. Like CCM, most RPM services are most efficiently delivered under general supervision, which does not require the physician and auxiliary personnel to be in the same building at the same time, and the physician could instead exert general supervision via telemedicine. This makes a huge difference in operations and business models.
- Will Medicare Pay for Setting Up the RPM Device and Patient Education?
Yes. CPT 99453 offers separate reimbursement for the initial work associated with onboarding a new patient, setting up the equipment, and patient education on use of the equipment.
- Must the Patient be in a Rural Area for RPM Reimbursement?
No, the patient need not be located in a rural area or any specific originating site. Providers frustrated with the labyrinthine and narrow Medicare coverage of telehealth services can take comfort in the fact that RPM is not considered a Medicare telehealth service. Instead, like a physician interpretation of an electrocardiogram or radiological image that has been transmitted electronically, RPM services involve the interpretation of medical information without a direct interaction between the practitioner and beneficiary. Medicare pays for RPM services under the same conditions as in-person physicians’ services with no additional requirements regarding permissible originating sites or rural geographies.
- Can the Patient be at Home for RPM Reimbursement?
Yes, patients can receive RPM services in their homes.
- Does RPM Require a Face to Face Exam or Interactive Audio-Video?
RPM services do not require the use of interactive audio-video, as these codes are inherently non face-to-face. A few groups urged CMS not to be prescriptive regarding the technology that could be used to perform consultations, including real-time video, a store-and-forward visit, or simply a patient-provider message via a patient portal. CMS expressed sympathy with the desire not to be overly prescriptive about the technology used to furnish RPM services, and stated it defers to the CPT code descriptors and guidance to ascertain the technological modalities used to furnish RPM services.
However, for new patients or patients not seen by the practitioner within one year prior to billing RPM, the practitioner must first conduct a face-to-face visit with the patient (e.g., an annual wellness visit or physical). E/M services levels 2 through 5 (CPT codes 99212 through 99215) should qualify for this face-to-face visit. Transitional care management (TCM) services should also qualify. However, services that do not involve a face-to-face visit by the billing practitioner or which are not separately payable under Medicare (e.g., online services, telephone and other E/M services) would not qualify as an initiating visit.
- Must the Patient Give Consent to RPM Services?
Yes, the practitioner must get the patient’s consent for RPM services and document it in the patient’s medical record. Although CMS did not directly address this in the final rule for the new codes, it is a requirement for CPT 99091 and can likely be expected as a requirement for CPT codes 99453, 99454, and 99457.
- Is there a Patient Co-Payment for RPM Services?
Yes, as a Medicare Part B service, the patient is responsible for a 20% co-payment for RPM services. While several groups asked CMS to eliminate any beneficiary co-payment for RPM services, CMS explained that it does not have the authority to change the applicable beneficiary cost sharing for most physician services, including RPM. Providers are cautioned to bill the patient (or the patient’s secondary insurer) for the co-payment, as routine waivers of patient co-payments can present a fraud & abuse risk under the federal Civil Monetary Penalties Law and the Anti-Kickback Statute.
- Can RPM Also Be Billed with Chronic Care Management (CCM)?
Yes, a provider can bill both CPT 99457 and CPT 99490 in the same month. This is allowed because CMS recognizes the kind of analysis involved in furnishing RPM services is complementary to CCM and other care management services. However, time spent furnishing these services cannot be counted towards the required time for both RPM and CCM codes for a single month (i.e., no double counting). Accordingly, billing both requires at least 40 minutes total (20 minutes of CCM and 20 minutes of RPM).
Healthcare providers should begin launching RPM programs:
Healthcare providers service Medicare patients should consult with companies, such as mTelehealth, to deliver RPM services to patients, similar to what we have seen with Chronic Care Management (CCM) companies. This is because the new codes expressly allow the use of “clinical staff” to help fulfill part of the 20 minutes per month. Current CMS guidance on CCM services expressly contemplates and allows third-party companies to contract with Medicare providers to help deliver CCM services. In order to further enable that, CMS created an exception allowing a Medicare provider to bill CCM services as “incident to” under general supervision. Normally, most services billed incident to must be provided under the direct supervision of the provider.
Healthcare providers should prepare for these new opportunities:
The first thing is to take the time to truly understand, with precision, the billing and supervision rules fundamental to a compliant RPM service model. Providers should not focus too much on the technology and business development until they are confident the model they are “selling” or delivering does, in fact, comply with Medicare billing requirements.
Second, providers should take time to develop a model business-to-business RPM contract with mTelehealth, whether this is technology-only, support services-only or a combination of both.