Remote Monitoring Coding and Reimbursement

Learn how to get reimbursed using remote monitoring tools in your practice.

On Dec. 28, 2020, the Centers for Medicare and Medicaid Services (CMS) finalized the CY 2021 Medicare Physician Fee Schedule (MPFS). The 2021 MPFS revises current care management services such as remote physiologic monitoring treatment management services (RPMTMS), transitional care management (TCM), chronic care management (CCM), principal care management (PCM) and behavioral health integration (BHI) coverage and payment policies. CMS’s care management services were created to improve the treatment of ongoing chronic conditions. Some states have also adopted these services and associated codes in their Medicaid fee schedules, as have select private payers.

In response to the COVID-19 pandemic, the Coronavirus Aid, Relief, and Economic Security Act (the CARES Act) was signed into law on March 27, 2020. The CARES Act contains several provisions affecting healthcare benefits and the expansion of telehealth and virtual care services. Some of those provisions and the resulting policy changes are highlighted below, and it seems likely that more are to come as the public health emergency continues, potentially into 2022.

About Remote Monitoring

The Center for Connected Health Policy defines "remote patient monitoring" (RPM) as the use of "digital technologies to collect medical and other forms of health data from individuals in one location and electronically transmit that information securely to healthcare providers in a different location for assessment and recommendations."

"This type of service allows a provider to continue to track healthcare data for a patient once released to home or a care facility, reducing readmission rates."

The definition and categorization for RPM vary from payer to payer. Medicare does not consider RPM to be a telehealth service. There is separate coverage and payment for remote monitoring and other virtual care services. Recently, many of the requirements around telehealth have been loosened or waived in response to the public health emergency. (For more details, see “Policy changes related to COVID-19” section below.) Because the definition for telehealth varies, other entities and payers, including some state Medicaid programs, use the term RPM interchangeably with telehealth or telemedicine services. The World Health Organization, for example, has adopted a more expansive definition of telehealth.

woman-on-telemedicine-call

Coding: Care Management Services

Remote Physiologic Monitoring / Treatment Management ServicesChronic Care ManagementPrincipal Care Management

Remote Physiologic Monitoring CPT® / Treatment Management Services

Remote physiologic monitoring treatment management is a clinical service that uses technology to enable monitoring of patients’ physiologic data outside of conventional clinical settings. The provider can also be reimbursed for onboarding and patient education, the device supply, patient monitoring and management of their condition.

CODE
Who
How often
How much
(Medicare Rate)*
CODE99453
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
 
WhoMust be ordered by physician or qualified health care professional (QHCP)**

Auxiliary personnel (including those “not clinical staff” but employees or leased or contracted employees) are allowed to furnish services under the general supervision of the billing physician or practitioner.
How often Should be reported only once during a 30-day period (even when multiple medical devices are provided to a patient), can be billed by only one practitioner, only once per patient per 30-day period and only when at least 16 days of data have been collected
How much (Medicare Rate)*$19.19 (Both non-Facility and Facility)
CODE99454
Device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days
 
WhoMust be ordered by physician or QHCP**

Auxiliary personnel (including those “not clinical staff” but employees or leased or contracted employees) are allowed to furnish services under the general supervision of the billing physician or practitioner.
How oftenShould be reported only once during a 30-day period (even when multiple medical devices are provided to a patient), can be billed by only one practitioner, only once per patient per 30-day period and only when at least 16 days of data have been collected
How much (Medicare Rate)*$63.16 (Both non-Facility and Facility)
CODE99457
Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes
 
Who Performed by physicians and non-physician providers (NPP) who are eligible to furnish evaluation and management, or auxiliary personnel/clinical staff under the general supervision of the billing provider
How oftenPer calendar month
How much (Medicare Rate)*$50.94 (Non-Facility Rate)
$31.75 (Facility Rate)
CODE99458
Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; additional 20 minutes
 
Who Performed by physicians and non-physician providers (NPP) who are eligible to furnish evaluation and management, or auxiliary personnel/clinical staff under the general supervision of the billing provider
How oftenPer calendar month
How much (Medicare Rate)*$41.17 (Non-Facility Rate)
$31.75 (Facility Rate)
CODE99091
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 healthcare professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days
 
Who Performed by physician or other QHCP, not clinical staff
How oftenReported each 30 days
How much (Medicare Rate)*$56.88 (Both non-Facility and Facility)

*Centers for Medicare & Medicaid Services, revisions to payment policies under the Medicare Physician Fee Schedule, quality payment program and other revisions to Part B for CY 2021, https://www.cms.gov/medicare/physician-fee-schedule/search.

**Under Medicare, CPT codes 99453 and 99454 are both practice-expense-only codes. Practice expenses are made up of direct (resource based) and indirect (specialty based) expenses incurred when furnishing services and do not include physician/NPP time or work.

Non-Complex and Complex Chronic Care Management CPT/HCPCS Codes

With CCM, the clinician provides or oversees the management and/or coordination of services for multiple chronic conditions, psychosocial needs and activities of daily living. These services should include “establishing, implementing, revising, or monitoring the care plan, coordinating the care of other professionals and agencies, and educating the patient or caregiver about the patient’s condition, care plan, and prognosis.” The codes are geared toward primary care physicians but can be billed by any physician or qualified healthcare professional who fulfills the code requirements.

CODE
Who
How often
How much
(Medicare Rate)*
CODE99490
Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care 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.
 
Who Clinical staff directed by a physician or other QHCP (general supervision required)
How often Per calendar month
How much (Medicare Rate)*$41.17 (Non-Facility Rate)
$31.75 (Facility Rate)
CODE99439
[Add-on code for 99490] Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month
 
Who Clinical staff directed by a physician or other QHCP (general supervision required)
How often Per calendar month; can only be billed twice in 1 calendar month
How much (Medicare Rate)*$37.69 (Non-Facility Rate)
$28.26 (Facility Rate)
CODE99491
Chronic care management services, provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, 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.
 
WhoPerformed by physician or other QHCP, not clinical staff
How often Per calendar month
How much (Medicare Rate)*$82.35 (Both non-Facility and Facility)
CODE99487
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 health care professional, per calendar month.
 
Who Clinical staff directed by a physician or other QHCP (general supervision required)
How often Per calendar month
How much (Medicare Rate)*$91.77 (Non-Facility Rate)
$51.29 (Facility Rate)
CODE99489
[Add-on code for 99487] each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month
 
Who Clinical staff directed by a physician or other QHCP (general supervision required)
How often Per calendar month
How much (Medicare Rate)*$43.97 (Non-Facility Rate)
$25.82 (Facility Rate)

*Centers for Medicare & Medicaid Services, revisions to payment policies under the Medicare Physician Fee Schedule, quality payment program and other revisions to Part B for CY 2021, https://www.cms.gov/medicare/physician-fee-schedule/search.

Principal Care Management HCPCS Codes

PCM services are similar to CCM with a key difference: management oversight is for a single chronic condition. CMS created these services to encourage holistic care management including beneficiaries with single chronic conditions. These services have the same billing qualifications as CCM codes. They are geared toward specialists who care for a patient’s sole condition but can be billed by any physician or qualified healthcare professional who fulfills the code requirements.

CODE
Who
How often
How much
(Medicare Rate)*
CODEG2064
Comprehensive care management services for a single high-risk disease, e.g., Principal Care Management, at least 30 minutes of physician or other qualified health care professional time per calendar month with the following elements: One complex chronic condition lasting at least three months, which is the focus of the care plan; the condition is of sufficient severity to place patient at risk of hospitalization or have been the cause of a recent hospitalization; the condition requires development or revision of a disease-specific care plan; the condition requires frequent adjustments in the medication regimen, and/or management of the condition is unusually complex due to comorbidities.
 
WhoPerformed by physician or other QHCP, not clinical staff
How often Per calendar month
How much (Medicare Rate)*$92.37 (Non-Facility Rate)
$76.77 (Facility Rate)
CODEG2065
Comprehensive care management services for a single high-risk disease, e.g. Principal Care Management; at least 30 minutes per calendar month of clinical staff time directed by a physician or other qualified health care professional with the following elements: one complex chronic condition lasting at least three months, which is the focus of the care plan; the condition is of sufficient severity to place patient at risk of hospitalization or have been cause of a recent hospitalization; the condition requires development or revision of disease specific care plan; the condition requires frequent new adjustments in the medication regimen; and/or the management of the condition is unusually complex due to comorbidities.
 
Who Clinical staff directed by a physician or other QHCP (general supervision required)
How oftenPer calendar month
How much (Medicare Rate)*$38.73 (Both non-Facility and Facility)

*Centers for Medicare & Medicaid Services, revisions to payment policies under the Medicare Physician Fee Schedule, quality payment program and other revisions to Part B for CY 2021, https://www.cms.gov/medicare/physician-fee-schedule/search.

Remote Monitoring Reimbursement and Outcomes

One example of how to bill for remote care:

Reimbursement can offset staff time to help support patient care

*Based upon Medicare non-facility rates from 2019 Physician Fee Schedule.
**This is a hypothetical scenario. Results will vary based on actual practice. Salary information sourced from Glassdoor (August 2019)

Remote monitoring programs are proven to improve health outcomes for patients

less rescue inhaler use1
reduction in COPD-related healthcare utilization2
reduction in asthma-related healthcare utilization3

1 Barrett et al. (2018). Health Aff
2 Alshabani et al. (2019). J Telemedicine and Telecare
3 Merchant et al. (2018). World Allergy Organ J

Policy changes related to COVID-19

As a result of the COVID-19 public health emergency, on March 6, 2020, the “Coronavirus Preparedness and Response Supplemental Appropriations Act” was signed into law. This would signal the first of several legislative enactments including the Families First Coronavirus Response Act (signed into law on March 18, 2020) and the Coronavirus Aid, Relief and Economic Security (CARES) Act (signed into law on March 27th, 2020). Importantly, the enactments expand regulatory waivers around telehealth and remote care to reduce burdensome requirements on providers and health systems. Below are some policies that have resulted from this effort.

telemedicine
  • The Office of the Inspector General (within the Department of Health and Human Services), is allowing physicians and other healthcare providers to waive patient cost-sharing payments for telehealth services and other non-face-to-face services like monthly remote care management and remote patient monitoring for the duration of the public health emergency.
  • A temporary safe harbor is allowing high-deductible health plans (HDHP) to cover telehealth services and other remote care without cost to plan members before plan members’ deductibles are met. This applies to all HDHPs, including those with plan members using HSAs.
  • The Federal Communications Commission has implemented a $200 million program to fund telehealth services and some end user devices for healthcare providers and to cover the costs associated with some services and personnel.

Disclaimer: The reimbursement information is being provided on an “as is” basis with no express or implied warranty of any kind and should be used solely for your internal informational purposes only. The information does not constitute professional or legal advice on reimbursement and should be used at your sole liability and discretion. All coding, coverage policies and reimbursement information are subject to change without notice. Propeller Health does not represent or warrant that any of the information being provided is true or correct and you agree to hold Propeller Health harmless in the event of any loss, damage, liabilities or claims arising from the use of the reimbursement information provided to you. Before filing any claims, it is the provider’s sole responsibility to verify current requirements and policies with the applicable payer.

The use or reprinting of Current Procedural Terminology® (CPT®) requires a license, unless such use is exempt under U.S. Copyright Law (Chapter One, Section 107), allowing limited uses of copyrighted works, referred to as "fair use." Such uses are permissible without a license. AMA® holds copyright in CPT®.

Frequently Asked Questions

What types of technology can be used to deliver RPM services?

CPT and CMS have not specified the types of technology — whether software applications, smartphones, etc. — required to fulfill the requirements of the code. However, CPT specifies that the device used for remote physiologic monitoring must be a medical device as defined by the FDA. In the 2021 Physician Fee Schedule Final Rule (CMS-1734-F), CMS further clarifies that the medical device should digitally (that is, automatically) upload patient physiologic data that is not patient self-recorded and/or self-reported. The device must be used to collect and transmit reliable and valid physiologic data that allow understanding of a patient's health status in order to develop and manage a plan of treatment.

Does the healthcare provider (HCP) need to provide the medical device in-office to bill for 99453-- an RPM CPT code for initial set-up and patient education of a device?

No, the actual device does not need to be provided or installed in the office to qualify for reimbursement under 99453. The provider can arrange for a third-party provisioner to send the device to the patient.

Additionally, for the duration of the public health emergency, CMS is not requiring that HCPs have a pre-existing relationship with a patient before they begin utilizing RPM codes. Therefore, steps like educating the patient on a new device or program can happen remotely.

What is "interactive communication" as required by 99457 and 99458?

In order to bill codes 99457 and 99458, CMS requires an “interactive communication” between a patient and the physician, NPP, or clinical staff that at a minimum occurs in real-time, synchronous, two-way audio. CMS describes this as “a conversation” capable of being enhanced with video or other kinds of data transmission. CMS also clarified that the 20 minutes of work associated with 99457 and 99458 includes the time engaged in “interactive communication” as well as time engaged in non-face-to-face care management services during a calendar month.

Why were CCM codes created as CPT codes whereas the PCM codes were created as HCPCS Level 2 codes? Are there any implications on how I can use the codes as a result of the differences?

Chronic care management codes were created by CPT to incentivize HCPs to take a more holistic approach to patient care. This should help decrease the cost of secondary and tertiary care. However, due to the requirement that the patient have two or more chronic conditions, CMS felt that there was a gap in billing and reimbursement for specialists who were treating patients with only one chronic condition. Therefore, CMS created principal care management codes (HCPCS Level 2 codes) as a way of filling the gap. In the 2020 Physician Fee Schedule, CMS further stated that it is "also possible that the patient could receive PCM services from more than one clinician if the patient experiences an exacerbation of more than one complex chronic condition simultaneously."

I understand that the Office of the Inspector General (OIG) is allowing HCPs to waive copays and other forms of coinsurance for telehealth and remote care services for the duration of the public health emergency. Does this only apply to my Medicare and Medicaid patients? As a HCP, am I allowed to waive cost-sharing for some patients and not others depending on their health plan?

The OIG declaration does only apply to patients on Medicare, Medicaid and Medicare Advantage plans. However, many commercial payers have adopted this policy as well, so providers should reach out to any other payers they are contracted with to find out if their policies have changed. At this time, the IRS is also not requiring that high deductible health plans require that patients pay out of pocket for telehealth and remote care services even if their deductible has not been met. Providers have the discretion to pass along costs to patients however they choose to. These policies simply give providers the option to waive cost sharing.