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2021 Medicare Physician Fee Schedule: 101

By Elena Muller, MPH

In December of last year, the Centers for Medicare and Medicaid Services (CMS) finalized new reimbursement policies for remote patient monitoring (RPM). These changes are included in the 2021 Physician Fee Schedule final rule. In the ruling, CMS confirms some of the changes made during the PHE as permanent, while noting others will expire at the end of the PHE.

The 2021 rule finalized many of the proposals released in August of 2020, and expands upon previous RPM guidance.


Starting with The Basics

Remote patient monitoring includes “periodic, asynchronous, or continuous monitoring and transmission of vital signs, including weight, blood pressure, oxygen saturation, glucose levels, heart rate, or heart rhythm.” It involves the collection and analysis of patient psychologic data to manage a patient’s medical condition.

There are 5 primary RPM codes:

  1. 99091 can be billed $59 once per 30-day period for a minimum of 30 minutes of review data only by physicians or qualified health care professionals
  2. 99453 covers the set up and patient education on RPM equipment including initial setup of devices, training and education, and any services needed to enroll the patient on-site ($21)
  3. 99454 covers remote monitoring of physiological data with a device; reimbursement of $69 can be filed once every 30 days
  4. 99457 provides a $54 reimbursement each calendar month for a minimum of 20 minutes of live communication with the patients by physicians, qualified health care professions or clinical staff
  5. 99458 is an add-on for CPT code 99457 and cannot be billed as a standalone code; it is used for each additional 20 minutes of remote monitoring (allows for $43 in billing per calendar month)

    remote blood pressure


Previously CMS did not prescribe an ideal “order of events” for RPM programs, but they did in this ruling. CMS stated the following “order of events:”

  1. After analyzing and interpreting the patients RPM data, the data must be analyzed and interpreted as described by CPT code 99091
    • 99091 only includes professional work including a total of 40 minutes of physician or non-physician practitioner work, 5 minutes of chart review, 30 minutes of data analysis and interpretation, and 5 minutes of post-service work

  2. Physician or non-physician practitioner develops a treatment plan informed by the RPM data

  3. Physician or non-physician practitioner manages the treatment plan until the patient’s goals are reached
    • CPT code 99457 and its add-on code, CPT code 99458, describe the treatment and management services associated with RPM and include work of both professionals and clinical staff.

  4. The episode of care ends

 

Important Components of the Rule 

Chronic and Acute Conditions

A patient does not have to have a  chronic condition to qualify for RPM. In the 2019 ruling, CMS required patients to have a chronic condition to receive RPM services. The 2021 rule states that practitioners may furnish RPM services to patients with acute conditions as well. 

Established Patients & Patient Consent

CMS has permitted that during the PHE, patients can give consent when the service is being provided. This ruling will remain beyond the pandemic.

Per the final rule, RPM services are limited to “established patients.” During the PHE, CMS waived the “established patient” restriction. The 2021 Final Rule does not extend the waiver beyond the PHE (which is still ongoing). Once the PHE is over, there will need to be an established relationship between the provider and patient. Once there is an established relationship, the provider can bill Medicare for CPT codes 99453, 99454, 99457, and 99458.

  1. Important to note, CMS allows real-time audio video technology (virtual visits) to satisfy the face-to-face requirement of an Evaluation and Management (E/M) service. New patient E/M service codes (99201-99205) are listed among the Medicare-covered telehealth services.
  2. In most cases, CMS defers to state laws on professional practice requirements, valid doctor-patient relationships, and clinical standards of care. Most state laws allow doctors to use telehealth to create a provider-patient relationship. 

Qualified Providers

RPM codes fall under the umbrella of Evaluation and Management (E/M) service. Only those eligible to bill Medicare for E/M services can bill for RPM (physicians or non-physician practitioners who are eligible).

  • CPT Codes 99457 and 99458 can be furnished by a physician or other qualified healthcare professional (QHCP)l, or by clinical staff under the general supervision of the QHCP or physician.
    • A clinical staff member is  “a person who works under the supervision of a physician or other qualified healthcare professional and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service but does not individually report that professional service.” 

  • In the 2021 Final Rule, CMS finalized its proposal to allow auxiliary personnel, in addition to clinical staff, to furnish services described by CPT codes 99453 and 99454 under the general supervision of the billing physician or practitioner.
    •  Auxiliary personnel include other individuals who are not clinical staff but are employees, or leased or contracted employees.  As noted in the 2021 Proposed Rule, CMS took this position because “the CPT code descriptors do not specify that clinical staff must perform RPM services.” 

Cadence of Billing

Per the ruling, ““even when multiple medical devices are provided to a patient, the services associated with all the medical devices 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.”  

  • For CPT codes 99453 and 99454 to be billed, monitoring must occur over at least 16 days of a 30-day period (once per period) - this requirement has been waived for the duration of the PHE, but will not extend beyond. At the end of the PHE, 16 days will be required for the codes aforementioned (CMS allows 2 days for COVID related diagnosis). The 16 days has not been waived, as mentioned on a recent NixonGwilt webinar.

RPM Monitoring and Management Codes

There are codes for RPM beyond the codes discussed at the beginning of this blog. There are more specific codes for billing including: 

  • 95250 - continuous glucose monitoring for a minimum of 72 hours
  • 99473 and 99474 - self-measured blood pressure monitoring

Moving Forward

While there are uncertainties that remain,  the 2021 Physician Fee Schedule is a step forward for those offering remote patient monitoring to their patients. While RPM services can still only be ordered and billed by physicians and others who can provide E/M services, ease of accessibility has broadened with the new ruling. 


Next Up: FCC COVID-19 Telehealth Program Part 2

 

Tags: Best Practices, reimbursement, COVID-19, News & Trends, Industry trends, Organization Type, Hospitals & Health Systems

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